Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Background: Studies indicate that patients with delirium require more nursing care. However, the extent of this additional nursing workload is unclear. Bundles of measures for delirium prevention and treatment measures to prevent and treat delirium cause a substantial and particularly high nursing workload.

Research question: What is the nursing workload involved in caring for patients with delirium compared to patients without delirium, and to what extent does it differ?

Method: A systematic literature search was conducted in the PubMed, CINAHL, and Cochrane Library databases. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS).

Results: Eight studies conducted in hospitals over the past 15 years were included. The mean quality of the studies was 6.1 out of a possible 9 NOS points (standard deviation 0.8). The nursing workload for patients with delirium is consistently higher when indices are applied and when workload recording tools are used. Patients with delirium require more frequently nursing interventions with two nurses and more time for observation, monitoring, and nursing care because of falls.

Conclusion: Patients with delirium require more nursing care than patients without delirium, regardless of the hospital setting. The delirium screening and (nursing) workload recording tools used in the eight studies showed a wide variation and, thus, limit standardized quantitative statements on nursing workload. The higher nursing workload of patients with delirium should be considered prospectively in nursing staff planning. In addition to the increased nursing workload, increased workloads for other health professional groups can also be assumed.

In addition to intensive care medicine, focused transesophageal echocardiography (fTEE) is increasingly being used in emergency departments. fTEE should only be performed as part of advanced cardiopulmonary resuscitation or in cases of unclear shock if a particular issue cannot be clarified using focused transthoracic echocardiography (cardiac point-of-care ultrasound [cPOCUS]). The conditions, indications and performance of fTEE are summarized in this consensus paper in terms of quality management in echocardiography in clinical acute and emergency medicine.

Background: CAR-T cell (chimeric antigen receptor T) therapy is now part of standard of care treatment of B‑cell lineage malignancies. Although it is an effective treatment, it comes along with adverse side effects and toxicities that may require intensive care therapy. The costs related to critical care therapy in critically ill patients after CAR‑T administration have not been evaluated.

Patients and methods: Retrospective analysis of all patients who had received CAR‑T therapy and were admitted to the intensive care unit (ICU) of a tertiary care university medical centre in Germany between 1 January 2019 and 31 December 2022. Cause of admission and ICU therapy as well as treatment and total hospitals costs were evaluated.

Results: Thirty patients with a history of CAR-T cell therapy for underlying haematological malignancy were included. The median age of all patients was 60 years (interquartile range [IQR] 50-70) and 37% (n = 11) were female. 93% (n = 28) of patients had non-Hodgkin lymphoma and 7% (n = 2) had multiple myeloma. The cohort was stratified whether the ICU admission was CAR‑T therapy related (i.e. within 30 days after CAR‑T therapy; 73%, n = 22) or the admission was of an other cause (> 30 days after CAR‑T therapy) (27%, n = 8). The median duration from CAR‑T therapy to ICU admission was 6 (range 5-8) days in CAR-T cell therapy associated ICU admissions compared with 52 (range 31-126) days in other admissions. The overall illness severity on admission was numerically higher in CAR-T-related ICU admission compared to other admissions (46 vs. 43 points, p = 0.18). Vasopressor therapy (50% vs. 75%; p = 0.19), invasive mechanical ventilation (27% vs. 50%; p = 0.24) and renal replacement therapy (14% vs. 50%; p < 0.05) were used in CAR-T-associated admission compared to other admissions, respectively. The ICU mortality (23% vs. 50%; p = 0.15) was higher in patients with other ICU admission. Median total costs of the entire inpatient stay in hospital were € 27,845 (range 8661-368,286 €) in CAR-T-associated ICU admissions compared to € 59,234 (range 23,182-127,044 €) in the group of other ICU admissions (costs of the CAR‑T product not included).

Conclusion: In relation to the total costs of CAR-T-cell therapy (production of the CAR‑T product), therapy-associated complications have a relatively low impact on the costs and utilization of ICU resources.

Background: Sepsis is an acute, life-threatening multiple organ dysfunction triggered by an infection.

Methods: This guideline is an update of the S3 guideline "Sepsis-prevention, diagnosis, therapy, and follow-up care" (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaft [AMWF] Registry No. 079-001) of the German Sepsis Society (DSG) dated 31 December 2018. The update of the "Surviving sepsis campaign (SSC): international guidelines for management of sepsis and septic shock 2021" dated 4 October 2021, was used as the reference guideline. The DSG Guideline Commission compared each recommendation on the underlying PICO questions of the DSG Guideline 2018 (literature search until December 2018) with those of the SSC Guideline 2021 (literature search until July 2019) and evaluated the newly available published data (literature search until December 2024) by means of systematic update searches and literature reviews in compliance with the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and the AWMF.

Results: A total of 88 PICO questions were addressed, including those related to the diagnosis and treatment of infection and organ failure. Of these, two were agreed upon as statements, 29 as expert consensus, and 57 as evidence-based recommendations (26 with a strong and 31 with a weak recommendation grade). Compared to the previous 2018 guideline, 43 recommendations were reviewed but retained, 16 recommendations were modified, and 29 recommendations were newly issued.

Conclusion: Given the lack of evidence for numerous measures for the inpatient care of patients with sepsis or septic shock, old and new knowledge gaps were revealed. Among the evidence-based recommendations, the underlying GRADE quality of evidence was high for only 5 recommendations, moderate for 18 recommendations, low for 17 recommendations, and very low for 16. These evidence gaps can only be closed through future multicenter, noncommercial clinical trials. The update to the S3 guideline on sepsis includes some updates to the recommendations of the previous guideline. These updates will need to be incorporated into some of the case- and facility-specific quality assurance indicators of quality assurance (QA) procedure 2025. Impairments in health-related quality of life for survivors must be given greater focus in outpatient care.

Objective: Upper gastrointestinal bleeding (UGIB) is a common condition in emergency departments (ED). The aim of this study is to evaluate the effectiveness of the red blood cell distribution width (RDW) to albumin ratio and three types of shock index (SI) as predictors of adverse outcomes in patients with UGIB in the ED.

Methods: The study was designed as a retrospective, single-center study, and patients were screened using electronic medical records. Glasgow Blatchford, RDW/albumin ratio, SI, modified SI (MSI), and age SI were calculated, and adverse outcomes were defined as ICU admission, red blood cell transfusion, in-hospital mortality, and 30-day mortality. The effectiveness of these parameters in predicting adverse outcomes in UGIB patients admitted to the ED was evaluated.

Results: The study enrolled 174 patients, of whom 17.2% required admission to the ICU, 33.9% received red blood cell transfusions, and 10.3% died within 30 days. Patients with adverse outcomes had significantly higher SI, MSI, age SI, and RDW/albumin ratio values. All four indices were statistically significant predictors of adverse outcomes (area under the curve [AUC] SI: 0.676; AUC MSI: 0.706; AUC age SI: 0.778; AUC RDW/albumin: 0.787). Age SI showed significantly higher prognostic performance in predicting adverse outcomes than SI and MSI.

Conclusion: The present study suggests that SI, MSI, age SI, and RDW/albumin ratio may be useful in predicting adverse outcomes in patients with UGIB. The RDW/albumin ratio was effective in predicting mortality, while age SI showed a higher predictive ability for adverse outcomes compared to SI and MSI.

Background: Venovenous extracorporeal membrane oxygenation (VV ECMO) is an established support option for patients with very severe respiratory failure and played an important role during the coronavirus disease 2019 (COVID-19) pandemic. Bacteria and fungi can lead to severe infectious complications in critically ill patients. The aim of this study was to describe the microbiological spectrum of bacteria and fungi detected in patients with COVID-19-associated respiratory failure supported with VV ECMO in our center.

Methods: This retrospective single-center analysis included all patients with COVID-19-associated respiratory failure supported with VV ECMO in our center between March 2020 and May 2022. All findings from microbiological samples, taken as part of clinical routine assessment from initiation of VV ECMO until day 30 were included. Samples were described by site and time of detection and microbiological characteristics.

Results: From March 2020 through May 2022, 88 patients with COVID-19-associated respiratory failure received VV ECMO support at our center. In 83/88 patients (94.3%), one or more pathogens were found in microbiological samples. Most pathogens were isolated from samples from the respiratory tract (88.6%). Earliest detection occurred in samples from the respiratory tract with a median time of 5 days to first detection. The most frequently detected pathogens were Staphylococcus spp., Candida spp., Klebsiella spp., Escherichia coli and Enterococcus spp.

Conclusion: In this cohort of severely ill COVID-19 patients receiving VV ECMO support, pathogens were frequently detected.

Internal medicine and its associated subspecialities represent an important cornerstone of intensive care and clinical emergency medicine. This curriculum-compiled by members of the German Society of Medical Intensive Care and Emergency Medicine (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), the German Society of Internal Medicine (Deutsche Gesellschaft für Innere Medizin) including subspeciality societies, the Professional Association of German Internists (Berufsverband Deutscher Internistinnen und Internisten, BDI) and the German Association for Palliative Medicine (Deutsche Gesellschaft für Palliativmedizin, DGP)-presents an overview of knowledge, skills (competence levels I-III), behaviors, and attitudes necessary for the highest treatment quality for the internal medicine aspects of intensive care and emergency medicine. It includes general aspects of intensive care and clinical emergency medicine (structure and process quality, emergency department: primary diagnostics and treatment as well as the indication for subsequent treatment, resuscitation room management, clinical syndromes in intensive care medicine, diagnostics and monitoring, general therapeutic measures, ethics, hygiene measures, and pharmacotherapy). Subsequently, specific aspects concerning angiology/vascular medicine, endocrinology, diabetology and metabolism, gastroenterology and hepatology, geriatric medicine, hematology and medical oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology, and toxicology are addressed. Publications focusing on the content of advanced training are quoted to support this concept. The curriculum is written primarily for internists but may also show practicing intensivists and emergency physicians the broad spectrum of internal medicine diseases and comorbidities presented by patients admitted to the intensive care unit or the emergency department.